Vinod introduced the session and explained to the participants some of the issues and themes that the presenters would be addressing – urban marginal living and work. They would particularly focus on the romanticization of resilience and whether actions based on limited choices can be termed resilient. The COVID-19 pandemic created large disruptions but many in the margins survived and we ought to ask ourselves if that is being resilient. People sadly survive in spite of poor public health access – is that too a marker of resilience?
Can adaptation be resilient?
Is it possible to move beyond arguing just around precarity of livelihoods? Vinod pointed out the need to acknowledge and support people’s processes and invest in people’s universal public health care. Making people’s needs and aspirations central to urban planning is key.
ARISE aims to improve accountability and promote health and wellbeing of urban marginalized people living and working in urban informal settlements. The consortium targets the most marginalized dwellers in urban informal settlements.
The experiences of waste pickers
In all the settings that were presented, waste pickers are more often than not perceived as thieves and not workers. The circumstances in which they work are neglected and very hazardous. They have no protective wear, work long hours and the terrains they cover are usually very hard to traverse. They face a lot of stigma and are discriminated against by state, society and health systems. There are also gendered experiences when seeking care and they encounter many challenges in accessing social security. COVID-19 exacerbated all these pre-existing vulnerabilities and now there is an over-reliance on civil society organizations and philanthropists. They were forgotten in most of the strategies to curb the pandemic as the focus was on providing protective equipment and mass testing.
There are many health disparities in urban areas in India and health vulnerability to climate change is not divorced from general vulnerability. The urban poor experience health vulnerability in the form of poor and precarious living conditions, hazardous occupations and social exclusion from services. There is a general growing prevalence of non-communicable diseases and a big difference in the prevalence between the rich and the poor.
The health care system in India is characterized by multiplicity of providers, inadequate numbers, delay in accessing care, high costs that the vulnerable may not be able to afford out-of-pocket and a lack of dignified care for the vulnerable.
What can be done?
It is the role of the state to ensure availability and access to comprehensive care. There is a lack of Primary Health Care in urban areas and a reliance on secondary and tertiary care facilities including ambulatory care. There is need to create awareness among the general population, which includes the vulnerable, health care providers and policy makers, on the impacts of climate change on human health. The health care system must also be strengthened to reduce illnesses and diseases due to variability in climate. A proactive approach is needed.
The resilience debate
Urban informal settlement residents’ mechanisms for survival are seen as resilience. Resilience is often glorified and this is dangerous as it overshadows lack of accountability among governance actors and service providers. There’s need for thoughtful consideration of the various aspects of urbanization and a better understanding and involvement of urban vulnerable populations in decision-making. Investment in health and equity should be at the core of strengthening public health and not just for the sake of climate change.
The Gobeshona Global Conference on Research into Action is taking place from the 27 March to the 1 April. GOBESHONA provides an opportunity to bring together multidisciplinary scholars, policy-makers, researchers and practitioners from around the world to share their knowledge, research, and practical experiences on climate change issues with a broad range of themes, focusing on Locally – Led Adaptation Action (LLA) across different geographical regions. ARISE is delighted to host a session on, ‘Urban Marginality and Resilience expectations learning from ARISE – accountability action research in health.’ Please do register for the conference on this link and come to the ARISE session on this link.
31 March 2022, India Time: 10:30 AM – 12:00 Noon, BD Time: 11:00 AM – 12:30 PM, Kenya Time: 08:00 AM – 09:30 AM, SL Time: 05:00 AM – 06:30 AM, UK Time: 05:00 AM – 06:30 AM
Lately there has been a lot of focus on Urban Resilience, which expects actions from duty bearers and policy makers in investing into thinking building resilience among communities, particularly the poor who disproportionately bear the brunt of catastrophic and slowly induced climate related and other urban vulnerabilities. But what does our experience in engagement with poor urban communities tell us about their vulnerabilities, organically developed resilience strategy, and their expectations from others, particularly those that are accountable to their well being in general?
Do we need to look at urban resilience with a new lens and challenge some of the problematic viewpoints that have a potential to reduce the role of governance and accountability and replace them with self-resilience? This session, through examples of community engagement will present and discuss on this crucial but less discussed aspect of Urban Resilience.
Panel speakers
– Shrutika Murthy and Inayat Kakkar – researchers at The George Insitute for Global health. Shrutika and Inayat have been working with waste picking communities in Shimla and Vijaywada. – Wafa Alam – is a researcher at BRAC university’s James P Grant School Of Public Health based in Bangladesh. Wafa has been working with slum communities in Dhaka around poverty, health and livelihoods. – Dr. Aditya Pradyumna teaches at the Azim Premji University is working on Public Health with recent publication on Health Care inequity in Urban India. – Smruti Jukur is a trained Architect and Urban Planner by education and a researcher at SPARC. Smruti has been deeply involved in urban planning and infrastructure development planning in large informal settlements in India and Kenya.
By Noemia Siqueira, Helen Elsey, Jinshuo Li, Penelope A Phillips-Howard, Zahidul Quayyum, Eliud Kibuchi, Md Imran Hossain Mithu, Aishwarya Vidyasagaran, Varun Sai, Farzana Manzoor, Robinson Karuga, Abdul Awal, Ivy Chumo, Vinodkumar Rao, Blessing Mberu, John Smith, Samuel Saidu, Rachel Tolhurst, Sumit Mazumdar, Laura Rosu, Sureka Garimella
Marginalised urban residents living in slums and other areas of cities face difficulties in accessing healthcare. Frequently, the only healthcare available to these city dwellers are private or informal healthcare providers, where care comes at a high price and quality can be poor.
For low-income city residents, this can lead to people not seeking care due to the financial burden or being driven into deeper poverty to meet the costs of care. This can mean that their health conditions get worse and that they may be vulnerable to additional conditions, leading to spiralling poor health and poverty for the individual and members of their household.
In health economic language, vulnerable urban dwellers can face a severe economic burden when accessing healthcare. This burden can be translated into high out-of-pocket expenditures and a high percentage of catastrophic health expenditures (CHE), which happen when the patients’ healthcare spending exceeds a specified threshold from the household’s total income.
A group of ARISE researchers came together to investigate the economic burden of healthcare access for slum dwellers and other city residents in low- and middle-income countries (LMICs). To do this, we conducted a scoping review to find out information on this topic in existing literature.
We wanted to know how expenditure on healthcare differed among poor city dwellers and those living in slums in LMIC cities.
In this blog, we show the process of developing the scoping review and the main outcomes of this investigation.
A scoping review to produce evidence
A core activity of ARISE is to produce evidence that can be used to advocate for improvements in the health and wellbeing of marginalised urban residents in LMICs.
Scoping reviews have a great utility for synthesising research evidence and are often used to group existing literature in a given field. The University Libraries website states that “Scoping reviews are best designed when a body of literature has not yet been comprehensively reviewed or exhibits a large, complex, or heterogeneous nature not amenable to a more precise systematic review”.
Given the complexity and heterogeneity of the literature addressing the economic burden of healthcare access for marginalised urban populations, we agreed that a scoping review would be the appropriate approach to provide evidence on this theme.
The scoping process
We developed a collaborative review process with representatives from ARISE research partners in India, Bangladesh, Sierra Leone, Kenya and the UK. The review team had 21 collaborators from BRAC University in Bangladesh; LVCT Health and African Population and Health Research Center in Kenya; The Society for Promotion of Area Resource Centres and The George Institute for Global Health in India; the University of Sierra Leone in Sierra Leone; University of York, Liverpool School of Tropical Medicine, and the University of Glasgow in the UK.
The process aimed to strengthen research capacity which is one of the core elements of the ARISE Consortium’s work. Some members of the team had little experience with review design, so training at the Cochrane interactive learning platform was offered to provide concepts and methods applied in review studies. They were then able to put their learning into practice in the following review process.
To operationalise the review process, the review team was divided into three groups, core group: researchers with experience in conducting systematic reviews and/or data analysis; new reviewer group: junior researchers with little experience in review methods; and the advisory group: senior researchers with expertise in health economics or urban health. The core and new reviewer teams were responsible for developing all review activities, whilst the advisory team contributed to the interpretation of data.
In July 2020, we had a kick-off meeting to present and discuss the review protocol previously discussed with the review team. Before doing any systematic review of the literature, a detailed protocol that specified every step of the process was produced. In our second meeting, we discussed different review designs and the Cochrane course.
As our search of electronic academic databases retrieved many studies (N=5,673), the members of the core and new reviewer teams were reassigned into review sub-groups, each with three researchers including at least one member from the core team.
Each sub-group independently performed the review steps as illustrated in the flowchart below:
Disagreements arise in each step of the process over the inclusion or exclusion of studies, specific data extraction or scoring in the quality assessment of studies. To resolve the disagreements on steps 1 and 2, we had weekly meetings to debate each issue and reach consensus. Disagreements on steps 3 and 4 were resolved by the third reviewer of each sub-group.
Review outcomes
We classified the studies by their settings into:
City-wide: urban studies which categorised residents by deprivation level but made no specific reference to whether people lived in slums or not
Slum studies: urban studies with data collected only in slums, and
Slum and non-slum: urban studies with data collected in slum and non-slum areas
We identified 64 studies for inclusion, 28 were from India, five from Bangladesh and one from Kenya. Our search did not identify any studies conducted in Sierra Leone.
The literature came mainly from city-wide studies, with 37 studies and a total sample of more than 1.5 million people. City-wide studies had more publications including the calculation of CHE, 20 in total. Unspecified and other health conditions (i.e. injuries, acute disease, child health and tuberculosis) were mainly addressed by city-wide studies, while slum studies addressed mainly obstetric and/or neonatal care. For chronic conditions, city-wide studies had more publications, but the total sample size was similar for city-wide and slum studies (~70,000 individuals).
Main findings
We found different expenditure patterns across the study groups. Slum studies reported higher direct costs of accessing healthcare for acute conditions than city-wide studies (Slum: ranged from I$157 poorest quintile to I$408 richest quintile; city-wide: ranged from I$125 poor quintile to I$177 richest quintile); and lower direct costs for chronic conditions (Slum: ranged from I$789 poorest quintile to I$1,695 richest quintile; city-wide: ranged from I$2,552 poorest quintile to I$3,166 richest quintile).
The percentage of individuals incurring CHE across wealth quintiles also differed according to the study group. By using a 10% threshold of the annual household income, we found similar percentages of CHE across wealth quintiles in slum studies (20% on average). However, in city-wide studies, the poorest residents incurred higher percentages of CHE compared with better-off residents (poorest quintile: 46%; richest quintile: 18%).
We completed our scoping review in December 2021 after a huge effort from all team members. The commitment of the review team was crucial during this 1.5-year process as we had to deal with the tight agenda of the researchers and coordination across different time zones. The collaborative process was important to promoting a co-learning environment and a high-standard review.
Our next step is to translate the scientific findings into country-specific policy briefs with recommendations for action that are relevant to city and country contexts. We can then use the scoping review as a tool for advocacy and changes in policies to promote health and well-being for vulnerable urban residents.
Image credit: Kibera by Stefan Magdalinski is licensed by CC BY 2.0.
On World Cities Day, Kate Hawkins and Lynda Keeru explore how climate change is affecting lives of people in informal settlements.
The 2021 theme of World Cities Day is Adapting Cities for Climate Resilience. ARISE is focused on supporting people in urban informal settlements to claim their rights, particularly the right to health.
Given that environmental changes wrought by climate change – such as floods, storms and extreme temperatures – are a major threat to health and wellbeing, health advocacy and calls for state accountability are likely to be intertwined with pressure to improve the environment for city dwellers more generally.
Vulnerability to ill-health in cities is not uniform. People in informal settlements tend to be more at risk. In these settlements, health problems are more prevalent, there are poor sanitary conditions, overcrowding and inadequate housing.
Climate change adds another layer of disadvantage. Flooding can cause the contamination of drinking and standing water increasing the likelihood of water borne diseases and malaria. Cardiovascular and respiratory diseases are associated with rising temperatures as are exhaustion and rapid heartbeat among older people and those with medical conditions. Displacement due to flooding, mudslides or fires can lead to increased poverty and insecurity. This can exacerbate mental health problems, for example, stress and depression.
The view from Freetown
Speaking at the ‘COP26 Adaptation and Resilience Workshop: Climate Change and Global Health’, Joseph Macarthy provided a succinct overview of how climate change is shaping lives in Freetown, Sierra Leone.
Over the last 15 years, residents of the capital have experienced significant changes in the climate and rapid urbanization. Residents are experiencing high levels of deforestation and the use of this land for habitation. Flooding is caused by high tide currents and sea level rise. The vulnerability of the city to climate change is also due to its geographical location.
Freetown, like many other cities, is characterized by informal settlements; with about 35 percent of the population living in the city. Climate change effects are associated mostly with old housing conditions in those places which lack secure tenure; experience poor water and sanitation problems; have inadequate access to healthcare; and are exposed to a lot of environmental hazards. Furthermore, informal settlements are often located in low-lying coastal areas, hilltops, hill slopes, wetlands and flood plains. Coastal and hillside slums are most adversely affected by climate change and people live-in constant fear of losing their life, homes, and properties.
These settlements experienced flooding in 2013, 2015 and 2017 which destroyed several homes, facilities and organizations. High temperature is also a recurrent problem which generally leads to water scarcity and attendant hygiene and water borne disease problems. Heavy rainfall contaminates fresh water supplies, creates breeding grounds for mosquitoes, presents risks of water borne diseases’; transmission damages homes and causes disruptions to public transport, access to health services and provision of medical and relief supplies. Strong winds also wiped out almost an entire informal settlement very recently this year. These winds also caused fire because electrical polls were blown down in Susan’s Bay. A 2017 mudslide and flooding in the Freetown area caused by intense rainfall led to about 1000 deaths and displaced over 3000 people and damaged millions of dollars’ worth of properties.
These settlements are the most affected as they are least capable of coping with these situations. Within informal settlements the most vulnerable are those who live hand-to-mouth through physical labour, children and pregnant women, older adults, persons with disabilities, and persons with pre-existing or chronic conditions.
In the light of these challenges communities are implementing measures to make their environment safer. These include:
Relocation to less vulnerable areas
Settlement upgrading by people and groups (e.g. drainage clearance, cleaning and protection of water holes, monthly cleaning, strengthening roof tops, construction of retaining walls)
Settlement upgrading by NGOs and the government etc. (e.g. provision of piped water, sanitation improvement and the provision of infrastructure, early warning mechanisms –through text messages, TV and social media and disaster preparedness).
The creation of Community Based Disaster Management Committees as first responders
From the local to the global
At the event ‘Building resilience with equity –Perspectives from cities and neighbourhoods in the Global South’, Sheela Patel reflected on the role of national and global policy makers in mitigating climate change and associated harms. Communities, no matter how rigorous and committed they are, can only make limited change. The choices that cities and governments will make on climate issues, are going to determine whether the world cares for those who are poor and vulnerable or not.
We have to move from the project of modernity which has worked for a few people in the formal sector to one of sustainability that addresses minimum safety nets for all, particularly those in the informal sector. Data gathered in different cities during the COVID-19 pandemic demonstrates that health, water supply, sanitation and food security systems are completely unprepared to address this present and upcoming challenges.
It is likely that climate change and challenges and calamities, such as water shortages, will drive more people to urban areas. Who is planning for the exponential growth of cities? Given the xenophobia present in many cities who will support climate migrants? These questions should be central to our work on the Sustainable Development Goals.
Moving forward: The role of research
Joseph argued that climate change issues exist alongside epidemics such as Ebola and COVID-19 and other protracted health conditions. However, levels of epidemiological vulnerability in the city and the drivers of vulnerability are still not well understood due to data paucity. There’s limited research on the health impact of climate change and the most effective adaptation methods required to inform policy making.
Sheela’s view is that the architecture of research needs to change and to become more responsible. There is a need for local disaggregated data to lead local programme design and investment. This will require meaningful partnership with communities for transformational change. This point was echoed by Joseph who believes we must prioritise community participation and co-production as a way of strengthening their role in decision-making and to act as channels for communicating their problems, with a particular focus on the most vulnerable.
In our ongoing work ARISE will continue to be led by our community partners to focus on the issues that really matter to them.
Notes:
Sheela Patel is the founder of the Society for Promotion of Area Resource Centres (SPARC)
Joseph Macarthy is Director of Sierra Leone Urban Research Centre (SLURC)
The President’s Lecture 2021 webinar hosted by RSTMH brought about some thought provoking conversation and presentations from Professor Sally Theobald and her colleagues, Abriti Arjyal, Bachera Aktar and Zeela Zaizay.
The webinar was a great opportunity to share learning on analysing and addressing intersecting inequities in global health across different contexts, projects and health issues. The presentations demonstrated the power and the potential of social science, participatory process and co-production processes for change.
The event highlighted three different projects that focus on three different types of neglected areas. These are neglected countries: particularly fragile and shock prone contexts, neglected communities in urban informal settlements and neglected health issues or conditions like neglected tropical diseases and stigmatising skin conditions.
Metaphors exert a powerful influence on our daily lives and Sally used a very significant one as she launched her speech. We are all in the same storm, but we are not all in the same boat. COVID-19 has demonstrated that we live in an interconnected but unequal world. We are differentially positioned in terms of our vulnerabilities to the pandemic. COVID-19 has been seen as a spotlight that amplifies the existing inequalities; exposing and often exacerbating these inequities.
In the UK, black and minority ethnic groups and people living in cramped conditions have been particularly adversely affected. The pandemic has also impacted and exacerbated how inequalities play out on a global stage.
Engagement with a community health volunteer (CHV) in the photovoice process in Foyah District, Liberia. Photo: REDRESS
Neglected Countries
ReBUILD for resilience research consortium works in partnerships in Sierra Leone, Lebanon, Nepal and Myanmar. They focus on fragility in health systems because 2 billion people around the world live in fragile and conflict affected settings (FCAS). The number of poor people living in FCAS is expected to rise 60% from the current 17% according to projections from the World Bank and other organisations. These settings experience multiple health challenges that emanate from severe resource constrains, multiple shocks and stressors to the health systems like the COVID-19 pandemic, weak and contested institutions, as well as the absence of reliable routine data.
The ReBUILD consortium has a resilience framework which focuses and grounds health systems; and views them as complex adaptive systems with gender, equity and human rights also being central. Sally explained the intricacies of how all this works together to underpin ReBUILD’s work and focus on health systems strengthening and access to better health.
Human resources is a key area of focus and particularly, community health workers (CHWs). CHWs are critical bridges between often neglected marginalised rural communities and health systems. They have proved to be essential, trusted and first-line responders providing health services in settings affected by conflict; often juggling many different programmes. It is the cadre every vertical programme wants to link and work with; resulting in a host of responsibilities. COVID-19 has brought new challenged and layered additional responsibilities for them.
Abriti Arjyal presented findings from the consortium’s study; the gendered experiences of community (CTC) providers in Fragile and Shock Prone Settings: Implications for Policy and Practice during and Post COVID-19. The most vital information she shared is the fact that these cadres play an important role in the COVID-19 response. Their experiences and challenges are shaped by existing gender norms and challenges. Thus, understanding these and incorporating these in design and implementation of community health programmes would not only ensure effective roles of female CHW but also broadly serve to amend existing gender inequities among community providers.
Female Community Health Volunteers (FCHVs) gathered to plan for a community health campaign. Photo: HERD International
Neglected communities
Countries are urbanising fast and in cities one in three people live in urban settlements. Speaking about the ARISE consortium work, Sally mentioned that cities face innumerable challenges. Some of these include housing, food insecurity, water and sanitation, pollution, access to healthcare among others. Most of these are caused by long-standing neglect from states as well as residents’ limited voice and power.
Cities illustrate some of the world’s darkest disparities in income, health and wellbeing. The presentation spelt out the consortium’s vision and how they carry out their work; referencing Bangladesh.
Bachera Aktar, who presented on the Bangladesh ARISE work, indicated that new vulnerabilities and vulnerable groups emerged during the pandemic with anticipated impacts into the post-pandemic era.
COVID-19 has generated new challenges impacting the broader social determinants of health and wellbeing. Bachera summarised the diversity of methods and approaches they have used to support the co-production of research with peer researchers and communities living and working in informal settlements. She highlighted the importance of ongoing community engagement to support translating research into action.
Neglected conditions and diseases
The aim of the REDRESS project is to use a person-centered approach to evaluate existing health system interventions for the management of severe stigmatising skin diseases in Liberia. People centered approaches are at the heart of REDRESS; meaning consciously adopting the perspectives of individuals, families and communities; seeing them as participants as well as beneficiaries and responding to their needs and preferences in humane and holistic ways.
Zeela Zaizay spoke about the community engagement, involvement and participation that they have been using in REDRESS in Liberia. Community engagement in this setting facilitates problem identification, design, planning and implementation of programmes.
He outlined key priority areas in REDRESS including establishing community advisory boards and a Ministry of Health technical advisory board; involving people affected by severe stigmatising skin diseases and other community actors as peer researchers, using participatory methods to elevate and listen to community voices and ongoing sharing of learning.
Lessons learned
The pandemic has indeed illustrated that no one is safe until we are all safe. There is a need to understand disparate voices, perceptions and knowledge hierarchies in making decisions. Combined efforts are called for to promote key issues such as vaccine inequity and reviewing existing structures and systems around key issues like funding and vaccination politics.
Teamwork and partnership are essential for strengthening and supporting health systems that are inclusive, people centred and built on the diverse views, perspectives and experiences illustrated in the presentations.
There is a need for continuous discussions on challenging knowledge hierarchies and applying the use of innovative research methods including social science and participatory knowledge to build partnerships and action and equity.
It is not only an epidemiological pandemic but a social one, that has uncovered the perpetual global social, economic, health and political inequalities. Lynda Keeru and Kate Hawkins report back from a recent webinar, ‘Exposing the cracks: COVID-19 and global inequality’. Hosted by The Gender, Justice and Security Hub this event brought together researchers to discuss whether the pandemic can be used as a disruption to the system – exposing cracks that can be exploited to confront power and inequality – or whether it is business-as-usual – exacerbating inequalities and privileging those with power.
Uganda
Josephine Ahikire painted the clear divide that exists between the rich and poor in Uganda; further worsened by the pandemic. The wealthy in Uganda still move freely facilitated by permits issued to them by resident district commissioners. However, circumstances are completely different for the poor. They are the recipients of the strict lockdowns with minimal livelihood options. They can no longer meet their basic needs like putting a meal on the table as they depend on daily income and live hand to mouth. In an attempt to mitigate these challenges, the government put in place a ‘response for the vulnerable’ – a move in the right direction. However, this was slowed down by the process of identifying the vulnerable. That the government did not know who was vulnerable is alarming as they are the ones most affected by government policies. They are the people beaten on the streets, those who can’t access general healthcare, those that can’t find transport because public transport is prohibited and those who face hurdles when trying to access health services.
The situation in Uganda demonstrates the priorities of the government in investing in control and militarism than in facilitating the population to respond to the pandemic. This is an indication of the close connection between neo liberalism and rising militarism. Militarism is being legitimized as a response to a global health challenge and this is a pattern that is being seen in many other contexts.
South Africa
Faisal Garba explored how existing inequalities had been exacerbated in South Africa, through the lens of migrant rights. In the context of refugee protection, countries are using COVID-19 to double down on closures to try and further isolate and marginalize refugees and prevent them from accessing what they are entitled to. Countries are using controls on migration to demonstrate their control of the pandemic.
South Africa adopted migrant blind polices in dealing with the pandemic. An example of this is a policy that was executed by the state at the height of COVID-19. A grant was issued to support families and small businesses. However, one of the eligibility requirements was citizenship. This meant that refugees – who were in critical need of food and other necessities – were excluded, deepening the divide between locals and migrants.
The long-standing fallacious belief that began during the HIV/AIDS era in South of Africa that migrants spread diseases has been upheld during COVID-19. The narrative being peddled is that the porous borders provide a gap for migrants to come into the country with COVID-19. State officials unfortunately amplify this message, creating false unity by selling the idea of citizens protecting their country and their country’s health from people who come in with diseases.
India
Surekha Garimella began by outlining how poor people have struggled for decades and that COVID-19 has brought this to the fore and in doing so made many people uncomfortable. In India the lockdown meant the cessation of livelihoods for many. The extension of women’s care work within the family, community, or for the state has been a considerable burden. Lack of access to health services and health system disruption has led to home deliveries and associated deaths.
During COVID-19 the most marginalized who most need to access protective measures were the ones who got the least. This is happening in a context where people have for decades lived with a huge basic need deficit. The implementation of the Disaster Management Act provided the state with huge power. This was wielded to regulate the lower classes to prevent them from infecting the dominant classes.
Surekha made a powerful intervention about the role of research and researchers in the pandemic response. She argued that the evidence used to formulate public health policies during COVID-19 does not adequately take the poor into account. There is a need to challenge mainstream conceptions of what evidence counts and go beyond the biomedical. This needs to consider that actions have different implications depending on the different societal divisions whether it be class, gender, caste, or geographical location.
“I learnt so much from the webinar and the engaged speakers, who are embedded in a range of different contexts, working to better understand and strategically address the multiple inequities that are amplified by COVID-19. It was excellent to bring learning together across three sister GCRF hubs, on social justice, gender and equity, and I look forward to further joint dialogue and action.“ Sally Theobald, PI, ARISE hub
Speakers:
Kirsten Ainley – Associate Professor of International Relations and the Deputy Principal Investigator of the UKRI GCRF Gender, Justice and Security Hub
Heaven Crawley, MIDEQ Hub
Faisal Garba – Teaches Sociology at the University of Cape Town (UCT) and is the Co-Convenor of University’s Global Studies Programme and works with the Migration for Development and Equality Hub
Dr Surekha Garimella – Senior Research Fellow at the George Institute (@GeorgeInstIN), holds a PhD in Public Health, Gender and Work and works is part of the ARISE Hub
Dr Josephine Ahikire – Principal, College of Humanities and Social Sciences and former Dean, School of Women and Gender Studies and Co-Director on the UKRI GCRF Gender, Justice and Security Hub
This blog was co-produced by researchers and co-researchers in Sierra Leone to share our experiences mapping urban marginalized spaces.
We conducted GIS mapping of three informal settlements to identify key landmarks, physical features, environmental hazards, health risk areas and social groups. The purpose of this work is to use the map to aid participatory data analysis that will identify key health and wellbeing challenges within communities and make maps accessible to community members so they can use them as they wish.
Researcher and co-researchers mapping wooden bridge and drainage which is also use as dumping site in Cockle Bay Photo credit: Daphnée GOVERS, Researcher.
Building our capacity
Our Field team in Sierra Leone is comprised of eight researchers (three women and five men) and 15 co-researchers from across three project communities (seven women and eight men). Before taking up the GIS mapping of project communities (Cockle Bay,
Researchers and co-researchers doing boundary mapping in Moyiba community. Photo credit: John Smith, Researcher.
Dwarzark and Moyiba), we held series of workshops to build our capacity as researchers and co-researchers on how to use GPS for boundary mapping and Open Data Kit (ODK) to map services. Workshops were facilitated by CODOHSAPA’s mapping expert (Richard Bockarie) and the team’s capacity and confidence were improved for the intended task.
“We also learned about the GPS and surveying; it was the first experience for some of us. We acquired technical knowledge. We listened to each other; we held meetings. If we made mistakes, we would find ways to correct them and go back on the field. The mapping exercise also allowed us to know our communities better and what the real boundaries are of our communities.” (Co-Researcher)
Organizing the team and completing the mapping
Eight days was allocated for boundary and service mapping across three communities (five days for boundary mapping and three days for service mapping). Three researchers and five co-researchers were assigned to the Dwarzark community, three researchers and five co-researchers were assigned to the Moyiba community and two researchers and five co-researchers were assigned to the Cockle Bay community. One community pointer was assigned to each community. Dwarzark and Moyiba had more researchers due to larger land size and rugged terrain which makes it difficult to navigate. With limited equipment two GPS and three phones were allocated to each community.
Hanging Toilet (This is the most common toilet facility found at the coastline in Cockle Bay community)
Informal settlements have unique power dynamics. There are local chiefs found across these settlements who were installed by the local government either as tribal or community chiefs. They are charged with the responsibility of regulating customary or bye-laws in their communities. Before our activities began, community leaders (councilors, community chiefs, chairmen and chairladies) and other relevant stakeholders were informed about our objective. This was intended to enhance community buy-in.
In the field, the bigger group assigned to each community was divided into sub-groups in order to cover more ground and efficiently manage time. We also agreed that groups should have a briefing before and after every exercise per day. This was to help us build confidence and address unforeseen challenges.
Reflection from Co-researchers on mapping community boundaries and services
A reflexive session was held after the mapping exercise with co-researchers and community pointers on the importance of the features mapped and the usefulness of the maps to their communities, successes, challenges and lesson learnt from the mapping exercise. The following reflections were share by co-researchers:
Identifying health and wellbeing issues and environmental hazards
“It is important to map the health centre. If the mapping shows that there are no health centres, we can show the government that help is needed. It gives us information on what should be improved.” (Co-researcher; Fatmata B Sesay Moyiba community)
“The health center is a key feature in the community because they help the community people. The environmental hazards are important to map also. In Dwarzark community, we do not have dumping site, so people use the drainage to dump the waste. But this is not good because if rain comes, it will overflow.
Mapping the coastline boundary in Cockle Bay close to the Aberdeen creek Photo credit: Ibrahim Gandi, Researcher.
It is important to map these features to know what the issues are and to have improvement, for example constructing a dump site.” (Co-researcher; Zakiatu Sesay Dwarzark community)
“It was useful to map out important features within our communities. All of these features are important. In the Dwarzark community, those who are living in the upper part are very prone to disaster and deprived of certain facilities. Those who live down are a little better-off. These physical features are important to identify to gain in-depth understanding of the community.” (Co-researcher; Mohamed Sesay, Dwarzark community).
“All the features mentioned are important. The environmental features (flooding area and dumping area) are important to map. During this project, we categorized the communities as hillside or sea-side. The hillside communities have health hazards. Through the mapping and observation, we know where they are located, in which CDMC (Community-based Disaster management Committee, these are groups formed in every informal settlement to champion disaster mitigation activity within their communities.) were later notified, so that they would clean the areas.”
“The edge of the banking area is a particularly important feature to map. We need to identify this boundary. There are massive banking activities currently going on there which has changed the landscape of the community. Cockle Bay is situated on wet land and very prone to flooding.
Mapping the coastline boundary in Cockle Bay close to the Aberdeen creek Photo credit: Ibrahim Gandi, Researcher.
We are very scared that one day high tide and heavy rain will happen simultaneously, which has never happened before, but if it does happen the community would be seriously damaged. We need to work as a community to prepare ourselves for this day. We wouldn’t be able to save our properties, but we need to be ready to save our lives.” (Co-researcher; Frank Bubu Kamara Cockle Bay community)
“The boundary mapping is also important; it helps the community to know what the boundaries are. For the seaside communities, it is important to map the boundaries because people are banking. So, in 5 years, we will be able use the map to asses and indicate the extent of the banking activity and the threat it poses to the community” (Co-researcher; Esther B. Sesay Cockle Bay community)
Supporting to strengthen accountability mechanisms to address identified challenges
“My position influences my access to services in the community. In hilltop areas, it is hard to have water access especially for young girls. So, we sensitized the water manager on this issue and allocated a certain time for young girls to fetch water to protect them. This allows us to reduce issues related to teenage pregnancies and early marriage.” (Co-researcher; Zakiatu Sesay Dwarzark community)
“I am also a community animator for NGOs working in my community. So, people know me because of this community work. It makes me feel good. I am also the community chairlady and I control 32 taps in the community. This taps really helps the community by protecting young girls from early marriage and teenage pregnancies. It also prevents school dropout by enhancing water access.” (Co-researcher; Jamestina Sia Bayo Moyiba community)
“I am a CDMC chairlady, so it is important for me to map out the dumping site to organize the CDMC team to clean these areas and reduce health hazards. All of the features are really important for me to map since they allow me to better understand and coordinate programme more efficiently.”(Co-researcher; Zakiatu Sesay Dwarzark community)
“We had to explain to the dwellers that we were not surveyors but mapping the community boundaries as part of the ARISE research project so that they would let us pass. We learnt a lot about the GPS mapping techniques. Now we are able to map anything. It also allowed me to know more about my community.” (Co-researcher; Saud Kamara Moyiba community)
Building capabilities and capacities
“There was a good working relationship between the researchers and co-researchers in the field as always. We divided the team in two sub-groups, but the information circulated well between the groups allowing the work to be successful. We would meet every morning and do a briefing on how to tackle challenges in the field. We were happy to do the work, so we got the best out of everyone. For most of the co-researchers, it was the first time we were doing this work, and we were very enthusiastic.” (Co-researcher; Mohamed Bangura Dwarzark community)
“The researchers were very caring and respectful to us which helped a lot to get the work done. There was a good working spirit, we ate together etc.… This good interaction really helped realize the work.”
“It is important to have good pointers that know the community well for the work to go faster and easier.” (Co-researcher; Jamestina Sia Bayo Moyiba community)
“We are happy because we learnt a lot. As co-researchers we did our work on our own. (Co-researcher; Issa Tuary Moyiba community)
Challenges in mapping informal settlements
Mapping informal settlements comes with lots of unforeseen challenges that might be encountered. These can range from challenges of equipment, personnel, personnel, time management, geographical terrains of communities or the community residents themselves.
We underestimated the size of Dwarzark and Moyiba community, so it took more days to complete. To complete the mapping than we had anticipated.
Dumping site on the coastline of Cockle Bay community Photo credit: Samuel Saidu, Researcher.
The GPS had a technical fault which also delayed the pace of work. There were also doubts about whether to map certain areas as informal settlements or not. This is because some community zones had massive properties. In the end, the contested areas were mapped since the technical team and community pointers (who were selected because they lived in these communities) gave directions on how to draw appropriate boundaries.
Community members in Cockle Bay were fearful when they first saw the team mapping the boundaries. Community members repeatedly asked about whether it was part of the eviction process. The intervention of co-researchers and the community chief, allayed their fears. The community Chief assigned one community stakeholder to us so we could explain our objectives to residents. With support from the co-researchers and community pointers we were able to gain their trust.
It was difficult to take photos and map out boundaries on the coastline in Cockle Bay due to high tides. As a result, researchers had to wait for low tides to continue, causing delays.
Researchers and co-researchers climbing to map hill top areas in Dwarzark community. Photo credit: Samuel Saidu, Researcher.
There were few incidents of accidental falls and minor injuries sustained by some co-researchers and researchers during the mapping exercise. They were taken to the community center for treatment and we tried to find better ways of navigating rugged terrain using ropes and support to each other to cross rivers and climb hills.
Resident in Moyiba community reported to us about incident of violence and robbery in a section of the community. That section of the community was inaccessible by the team for several days.
Although faced with many challenges we were able to complete the mapping exercise. It was a great experience for us all, as we learnt new things about our communities, exhibited great teamwork and had fun.
Upon completion of the boundaries and service mapping, a draft map was produced and a validation workshop convened. The validation workshop comprised of all those who participated in the mapping exercise such as researchers, co-researchers and community pointers. During the validation session, co-researchers were asked what they wanted to do with these maps within their communities and for ARISE data analysis. They stated that they want to use the map to advocate for development in their communities and also to change the behavior of people doing banking, building in hazardous locations and for proper waste management. We are continuing to support communities to take forward their priorities.
Notes
Produced by (Researchers) Samira Sesay, Abu Conteh, John Smith, Dr. Bintu Mansaray, Mary Sarah Kamara, Daphnée GOVERS, Samuel Saidu, Ibrahim Gandi and (Co-researchers) Mohamed Bangura, Mohamed Sesay, Zakiatu Sesay, Sinneh Turay, Hafsatu Kamara, Jamestina Sia Bayo, Fatmata B Sesay Suad Kamara, Issa Turay, Abdul Karim Kamara, Alieu Bah, Frank Bubu Kamara, Esther A Kamara, Abu Sesay.
This blog was produced by Daniella Kennedy and Ibrahim Gandi, Research Assistant, CODOHSAPA. Daniella wanted to share her story as part of ARISE’s exploratory research phase in Dwarzark community, Sierra Leone. Daniella is a wonderful, friendly and peaceful person. She is strong and passionate about education. She wants to raise awareness about some of the challenges she faces trying to have a career and about the way people think about her within her community. She believes that her dreams can be achieved because she believes in the potential within herself.
My name is Daniella Kennedy. I am living with my parents and two brothers in Dwarzark community one of the informal settlements in Freetown, Sierra Leone. My father is a commercial bike rider ‘‘okada rider’’ and my mother looks after me and my two brothers. I was born with a physical form of disability called Locomotor disability. I can neither walk nor pick or hold an object, so I rely on my family for physical support. I am treated like anyone else in my family. I don’t feel like a person with disability in my family. I am loved by everyone including our neighbours.
My mother (Isata Kennedy) is a hardworking woman. She is strong and passionate about taking care of me and my brothers. She has really been supportive to everyone in this family, although she faces lots of challenges and ridicule from people.
‘‘People have been saying different things about my child’s disability and also asking several questions about my patience in taking care of Daniella from childhood to now. Some even say that if they were the ones that gave birth to such child, they would have dumped or killed her rather than wasting time to raise her. Despite all their comments, I am keeping and caring for my daughter. She is the only daughter I have now. I believe my child is a gift from God and she was born this way for a reason. I will not consider any option other than taking care of Daniella. My greatest challenge at this moment is carrying Daniella in and out of the house, through which I have sustained back pain.’’
At an early age, I was admitted in a Home for Children with Disability. However, due to distance and financial challenges, my parents decided to find me a school within our community. But ever since, I have been attempting to gain admission into schools within my community – I have not been successful in this effort.
I have been marginalized by denying me admission into the community schools. But maybe it is because of my disability, because I can’t make proper use of neither my hands nor my feet, I can’t walk or hold an object. I am not happy being born this way, especially when seeing girls of my age doing things that I may want to do but I can’t because of my disability. I feel so bad. At times, I am frustrated by not having the opportunity to go to school. I’m a friendly person and I always want to go out with my friends to play but I can’t. Instead, they always come to me. I have lots of friends and I learn a lot from them. We play, laugh, watch TV and eat together. They always come to me after school and I ask them lots of questions about what they learnt at school.
Due to my love for education, I have learnt over the years to read and write using my mouth by reading text books and notes brought home by my brothers and from my interaction with friends. They teach me a lot at home. I can also plait my doll using my mouth. I can do different styles on my doll. I want to fulfil my dream of being educated and having a career, but ever since I left the home for children with disability at age seven, I have not been able to gain admission into any school in my community. My parents decided to take me back to the home with support from FEDURP/CODOHSAPA after five years of trying but unfortunately, I am faced with a new challenge. I have developed too much weight for mother and other people to carry me on their backs. I have no assistive device to carry me around and I need constant attention and assistance from people at this stage. With all these challenges, the chairman of the Home clearly stated that the home has been operating on its policies since its establishment. They only admit children with limited form of disability. According to the chairman, he asserted that my condition does not fall under any of their categories and the home does not have the necessary provision to take care of me.
“We just do not have the financial and human capacity to look after Daniella. We have tried all we can as an institution to help her but our capacities are just too limited to support her. No provision exists at the home for people with such form of disability.”
Often emphasized by the chairman, this has sealed my fate that I cannot be readmitted into the Home for Children with Disability because there is no one to take care of me.
As mentioned earlier with no assistive device, I find it difficult to move around especially when there is no one around to help me. As such, I want people to support me to have access to an assistive device to aid my movement around. On top of that, I have also undergone series of operations in order to improve my condition, for which I need support to have access to proper medical service. Lastly, I want to go to school and have a career – but with so much financial challenges and marginalization, achieving my dream has been really the most challenging for me.
Daniella is one of many children with disability out there, who go through similar challenges. She does not have access to an assistive device to help her move around. At age seven she managed to get supplied with a locally made wheel chair during her time at the Home for Children with Disability. And now, after several years the chair is not in good condition and leaves Daniella in much pain whenever she uses it. As ARISE we will continue working with Daniella to understand and share her needs and priorities with the public and further advocate for change and integration in federation activities.
Digging into urban health: uncovering concepts and action for health and social justice in informal settlements
What’s it all about?
Rapid urbanization is re-shaping social and economic life and, with it, human health and health systems. Most of the world’s population is now urbanized, yet one-third of urban residents live in precarious ‘slums’ and ‘informal settlements’. These city-dwellers typically lack access to healthcare and vital health-supporting services. Slums are widespread in the Global South but often hidden in plain sight, reflecting residents’ lack of voice as well as sectoral and disciplinary silos. This session asks how health systems can better engage with the social, economic and environmental realities of informal settlements, in hopes of improving residents’ health and promoting social justice.
Urban areas often experience deeply entrenched health and social inequalities, but also concentrate knowledge, economic dynamism, and vibrant local organisations that can foster innovations in health-promoting practices. However, practical and conceptual approaches to deliver health systems for low-income urban residents often fail to address intersectoral challenges and the ubiquity of informality in the Global South. Vast amounts are spent on health services, while the social, economic and environmental determinants of health in informal settlements remain overwhelmingly neglected. Informal settlements are also poorly represented in official statistics, rendering them invisible to health officials and policymakers.
To reveal new insights into slums and urban health dynamics, the session will be organised like an archaeological dig: it will go beyond superficial observations to analyse the underlying structural determinants of health, and participating urban researchers, policymakers, and practitioners will foster interdisciplinary dialogue that can promote health equity and the broader 2030 Agenda.
Contributors
Mr Robert Hakiza, a Congolese refugee in Uganda and director of Young African Refugees for Integral Development, will highlight urban displacement and associated risks to well-being. In particular, how urban refugees living alongside other low-income residents in Kampala struggle to access housing and healthcare, and face additional challenges of discrimination, lack of documentation, or language barriers.
Mr Abu Conteh, an urban health researcher at the Sierra Leone Urban Research Centre (SLURC), will highlight the complex, undercounted health burdens in Freetown’s informal settlements, drawing on research into residents’ life histories and the roles of formal and informal governance structures.
Dr Alice Sverdlik, an urban researcher at the International Institute for Environment and Development (IIED, UK) will highlight how health in informal settlements is influenced by multi-level factors including household poverty; inadequate shelter, services and infrastructure; unresponsive local governance and exclusionary planning.
Dr Surekha Garimella is a researcher at the George Institute for Global Health (India) working on participatory approaches with waste-picking communities in Bangalore’s ‘informal spaces’. She will highlight collective community processes to improve health services entitlements for urban poor and marginalized residents.
Professor Sabina Faiz Rashid is an anthropologist and the Dean of the BRAC James P Grant School of Public Health. She will highlight the social and structural inequalities which contribute to health vulnerability in informal settlements in Bangladesh
On the 26 January 2021 the UK Government International Development Select Committee published a report on the secondary impacts of the COVID-19 pandemic. Kate Hawkins explains what’s in the report and the evidence that ARISE submitted to the process.
The International Development Select Committee has a mandate within the UK government to track and assess international development spending and policy and make recommendations where change is deemed necessary. In April 2020 they opened an inquiry into COVID-19 in low- and middle-income countries and then moved into a second phase later in the year that looked at the secondary impacts and how aid from the UK might mitigate them. It focused on:
Non-coronavirus health care
Economy and food security
Treatment of women and children
Our evidence
We felt it important that we shared evidence from our work in India, Bangladesh, Kenya and Sierra Leone. You can find a shortened version of the points we made in our blog for World Cities Day. We highlighted the effects of violence and mental strain brought about by the pandemic and measures to tackle it. Our evidence explored how daily wage earners were particularly hard hit and that particularly marginalised people in urban informal settlements – such as waste-pickers – were feeling the brunt of the pain. It highlighted the gendered affects of COVID-19 and its impacts on the most vulnerable.
The International Development Select Committee report
The inquiry found that routine healthcare in some countries is grinding to a halt; vulnerable economies risked failure under rising levels of national debt; people across the Global South were more in fear of threats of job losses and starvation than the pandemic; and the virus, and its counter-measures, were increasing levels of gender-based violence, child marriages and other challenges to girls access to education.
The findings of the inquiry echo many of the challenges that we have seen in the course of our work. They cite our work several times and highlight the importance of capturing data on COVID-19 in a manner that adequately reflects the real-world situation for marginalised groups which is disaggregated according to sex, ability, age, status etc. Throughout, they acknowledge that communities that were previously poor are being plunged into further crisis by the pandemic.
The report offers many recommendations for how aid from the UK can better organised. You can find the UK Government’s response to the report here.
We welcome the report and are grateful for the opportunity to provide evidence. Moving forward, we will be following future Select Committee inquiries and supplying data from our work where useful.
I have been marginalized by denying me admission into the community schools. But maybe it is because of my disability, because I can’t make proper use of neither my hands nor my feet, I can’t walk or hold an object. I am not happy being born this way, especially when seeing girls of my age doing things that I may want to do but I can’t because of my disability. I feel so bad. At times, I am frustrated by not having the opportunity to go to school. I’m a friendly person and I always want to go out with my friends to play but I can’t. Instead, they always come to me. I have lots of friends and I learn a lot from them. We play, laugh, watch TV and eat together. They always come to me after school and I ask them lots of questions about what they learnt at school.
